Nokea
A nurse is preparing to infuse ampicillin and gentamicin sulfate intravenously. Which resource should the nurse first consult for information on medication compatibility? Which resource should the nurse consult for compatibility?
- A. Hospital pharmacist
- B. Health care provider
- C. Medication sales representative
- D. Nurse manager
Correct Answer: A
Rationale: The correct answer is A: Hospital pharmacist. The pharmacist is the most appropriate resource for medication compatibility information because they have the expertise in drug interactions, contraindications, and compatibility issues. Pharmacists can provide detailed information on how ampicillin and gentamicin sulfate interact when given together intravenously. Consulting a pharmacist ensures patient safety by preventing potential adverse drug reactions. Health care providers may not have detailed knowledge of medication compatibility. Medication sales representatives may have biased information and limited expertise. Nurse managers are not typically trained in pharmacology and drug interactions. Consulting the hospital pharmacist is the best course of action to ensure safe administration of medications.
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A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
- A. I will call the doctor and get a prescription.
- B. I will cover the catheter so he can't see it.
- C. Let's wait until tonight to see if he continues this behavior.
- D. I will apply the restraints immediately.
Correct Answer: B
Rationale: The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? Which statement indicates a need for HIPAA teaching?
- A. A patient's address would be an example of personally identifiable information.
- B. HIPAA is a federal law, not a state law.
- C. HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form.
- D. Information about a client can be disclosed to family members at any time.
Correct Answer: D
Rationale: The correct answer is D because HIPAA protects the confidentiality of a patient's health information and restricts disclosure to family members without the patient's consent. This ensures privacy and security. Choice A is correct as a patient's address is considered personally identifiable information. Choice B is correct as HIPAA is indeed a federal law. Choice C is correct as HIPAA covers health information in various forms. Choices E, F, and G are not relevant to the question.
A nurse is caring for a patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Which finding should the nurse report during bladder irrigation?
- A. Urine output of 200 mL/hr
- B. Pink-tinged urine
- C. Clots in the drainage bag
- D. Bladder spasms
Correct Answer: C
Rationale: The correct answer is C: Clots in the drainage bag. This finding should be reported to the provider because it may indicate bleeding or clot formation, which can obstruct the catheter and impair the irrigation process. Clots can also increase the risk of urinary retention or infection. Reporting this finding promptly allows the provider to assess the patient's condition and take appropriate interventions to prevent complications.
Incorrect choices:
A: Urine output of 200 mL/hr is within the expected range for continuous bladder irrigation and does not necessarily indicate a problem.
B: Pink-tinged urine is a common finding following prostate surgery and is expected during bladder irrigation.
D: Bladder spasms are common after prostate surgery and can be managed with appropriate medications.
E, F, G: These choices are not provided, but they would be incorrect as they are not related to complications of bladder irrigation post-prostate surgery.
A nurse is caring for a patient who is receiving a blood transfusion. The patient reports chills and back pain 15 minutes after the transfusion begins. Which of the following actions should the nurse take first? What should the nurse do first for transfusion reaction symptoms?
- A. Slow the transfusion rate.
- B. Stop the transfusion.
- C. Administer acetaminophen.
- D. Notify the provider.
Correct Answer: B
Rationale: The correct answer is B: Stop the transfusion. When a patient develops symptoms of a transfusion reaction such as chills and back pain, it is crucial to stop the transfusion immediately to prevent further complications. This action takes priority over other options as it ensures patient safety. Slowing the transfusion rate (choice A) may not be sufficient to address the reaction promptly. Administering acetaminophen (choice C) may help alleviate symptoms but does not address the underlying cause. Notifying the provider (choice D) is important but should come after stopping the transfusion to address the immediate issue.
A nurse is caring for a patient hospitalized for the treatment of severe depression. Which of the following nursing approaches should be included in the patient's care plan? Which approach should be included for severe depression?
- A. Spend time sitting with the patient.
- B. Offer the patient choices of activities.
- C. Establish a patient relationship.
- D. Explore the truth of the patient's statements.
Correct Answer: A
Rationale: The correct answer is A: Spend time sitting with the patient. Spending time with the patient demonstrates empathy, support, and a willingness to listen, which are crucial for patients with severe depression. It helps build a therapeutic relationship and provides emotional comfort. Choice B focuses more on autonomy and may not address the patient's emotional needs. Choice C is important but is a broad concept that is encompassed by spending time with the patient. Choice D may come off as confrontational and potentially exacerbate the patient's distress.